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Table 7.15.1 Dietary recommendations for cancer prevention [based on the World Cancer Research Fund (WCRF) report on Food,
Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective (WCRF/AICR, 2007]
Public health goals
Be as lean as possible
within the normal
range of body weight
Median adult body mass index (BMI) to be 21–23 kg/m2
depending on the normal range for different
Level of overweight/obesity to be no more than the
current level, or preferably lower, in 10 years
The proportion of the population that is sedentary to
be halved every 10 years
Average physical activity levels >1.6
Maintenance of a healthy weight throughout
life may be one of the most important ways to
protect against cancer
Be physically active as
part of everyday life
Limit consumption of
energy dense foods
Avoid sugary drinks
Eat mostly foods of
plant origin
Limit intake of red
meat and avoid
processed meat
Average energy density of diets to be lowered towards
125 kcal/100 g
Population average consumption of sugary drinks to be
halved every 10 years
Population average consumption of non-starchy
vegetables and of fruit to be at least 600 g (21 oz)/day
Relatively unprocessed cereals (grains) and/or pulses
(legumes), and other foods that are a natural source of
dietary fibre, to contribute to a population average of
at least 25 g/day of non-starch polysaccharide
Population average consumption of red meat to be no
more than 300 g (11 oz)/week, very little if any of which
to be processed
Limit alcoholic drinks
Proportion of the population drinking no more than
the recommended limits to be reduced by one-third
every 10 years
Limit consumption of
Avoid mouldy cereals
(grains) or pulses
Population average consumption of salt from all
sources to be <5 g (2 g of sodium/day)
Proportion of the population consuming >6 g of salt
(2.4 g of sodium)/day to be halved every 10 years
Minimise exposure to aflatoxins from mouldy cereals
(grains) or pulses (legumes)
Maximise the proportion of the population achieving
nutritional adequacy without dietary supplements
Aim to meet
nutritional needs
through diet alone
Mothers to
breastfeed: children
to be breastfed
Cancer survivors:
follow the
recommendations for
cancer prevention
The majority of mothers to breastfeed exclusively for 6
All cancer survivors to receive nutritional care from an
appropriately trained professional. If unable to do so,
and unless otherwise advised, aim to follow the
recommendations for diet, health weight, and physical
Manual of Dietetic Practice, Fifth Edition. Edited by Joan Gandy.
© 2014 The British Dietetic Association. Published 2014 by John Wiley & Sons, Ltd.
Companion Website:
Most populations, and people living in
industrialised and urban settings, have habitual
levels of activity below levels to which humans
are adapted
Consumption of energy dense foods and sugary
drinks in increasing worldwide and is probably
contributing to the global increase in obesity
An integrated approach to the evidence shows
that most diets that are protective against
cancer are mainly made up from foods of plant
An integrated approach to the evidence also
shows that many foods of animal origin are
nourishing and healthy if consumed in modest
The evidence on cancer justifies a
recommendation not to drink alcoholic drinks.
Other evidence shows that a modest amount of
alcoholic drinks is likely to reduce the risk of
coronary heart disease
The strongest evidence on methods of food
preservation, processing and preparation shows
that salt and salt preserved foods are probably
a cause of stomach cancer, and that foods
contaminated with aflatoxins are a cause of
liver cancer
The evidence shows that high dose nutrient
supplements can be protective or can cause
cancer. The studies that demonstrate such
effects do not relate to widespread use
amongst the general population, in whom the
balance of the risks and benefits cannot
confidently be predicted. A general
recommendation to consume supplements for
cancer prevention may have unexpected adverse
effects. Increasing the consumption of the
relevant nutrients through usual diet is preferred
The evidence on cancer as well as other diseases
shows that sustained, exclusive breastfeeding is
protective for the mother as well as the child
Subject to the qualifications made in the WCRF
Table 7.15.2 Examples of alternative and complementary dietary regimens used by cancer patients
Dietary regimen
Main dietary principles
The Bristol Cancer
Centre Diet
The Centre believes that, as part of an
holistic approach, diet and nutritional
supplements can be important and may
well have an influence on recovery by
enhancing the effectiveness and
reducing side effects of cancer
treatment, improving wellbeing and in
some cases prolonging survival
Foods are classified as Yin foods,
representing feminine, dark and negative
principles, and Yang foods, representing
masculine, light and positive principles.
The aim is to balance these for each
individual in order to obtain a healthy
mind and body
Milk and dairy foods promote the
growth of cancer, particularly breast and
prostate cancer
Fresh fruit and vegetables
Organically grown foods
Whole grains
Organic poultry, eggs, game and fish in moderation
Beans and pulses
Freshly made fruit and vegetable juices
Supplements of vitamin C, beta-carotene, vitamin B complex,
selenium, zinc
Mainly based on cereal grains
Vegetables, sea vegetables and fruit
Bean and bean products
Nuts and seeds
Soup made with vegetables, beans and grains
Sea vegetables seasoned with sea salt, soy sauce or miso
Soya foods, including soya milk, are substituted for dairy
Increase consumption of fruit and vegetables (preferably
Avoid processed foods, including meats, oils, refined starchy
foods, alcohol and fizzy drinks
Fresh fruit and vegetables
Freshly made fruit and vegetable juices
Supplements of digestive enzymes, niacin, liver capsules,
iodine, thyroid extract, potassium compound and vitamin B12
Coffee enemas
Dairy free diets
Gerson therapy
Aim is to stimulate the body’s own
defence system to overcome cancer.
Both the nutritional and detoxification
parts of the therapy are required
Table 7.15.3 Factors contributing to malnutrition in head and neck cancer (source: Talwar 2010. Reproduced with permission of
Wiley-Blackwell Publishing)
Contributory factors
Poor dietary habits
Excessive alcohol intake
Depression and anxiety
Difficulty with chewing
Consumption of unbalanced meals can lead to energy, protein and micronutrient deficiency
Associated with appetite suppression, inadequate nutrient intake and micronutrient deficiency
These can result in aversion to food and/or loss of appetite with reduced quality of life
Lack of teeth, ill fitting dentures and physical problems with jaw movement can markedly affect
food choice in favour of a limited range of soft or liquid foods
Presence of the tumour mass, pain on eating, ulcerated mouth and fear of choking can
compromise the safety of swallowing and result in the consumption of a diet restricted in variety,
texture and nutritional content
Altered nutritional and metabolic response due to the presence of the tumour can result in
symptoms such as anorexia, loss of appetite, early satiety and marked weight loss associated with
muscle wasting and increased production of acute phase protein
Disturbance in energy balance with changes in resting energy expenditure, glucose uptake,
mobilisation of fat and protein stores, and muscle protein release
Anaerobic respiration with the production of lactic acid and subsequent build-up of ammonia
released via the mouth
Combined effect of the causes and consequences of malnutrition in this patient group, leading to
risk of starvation for longer than 7–10 days and unintentional significant weight loss
Patients who live alone or have no family can be less motivated and often find it more challenging
to maintain adequate nutrition
Increased risk of infection due to decreased muscle, respiratory, gut and immune functions
Nutritional deterioration requiring feeding management with greater length and cost of hospital
Increased lethargy and decreased ability to mobilise, work and socialise
Difficulty with swallowing
Changes in body composition
High risk of refeeding
Limited support network
Impaired wound healing
Higher risk of hospital
Poor functional status and
quality of life
Increased morbidity and
Poor nutritional status at presentation combined with malnutrition and its associated
consequences, limiting the options and choice of cancer therapy due to tolerance and therefore
contributing towards poorer tumour control and survival
Table 7.15.4 Effects of surgery and nutritional consequences (source: Talwar 2010. Reproduced with permission of Wiley-Blackwell
Effects of surgery
Nutritional consequences
Loss of taste
Surgery to the tongue, salivary glands or olfactory nerve negatively influence taste acuity, leading to
reduced appetite and gustation
Loss of nasal airflow via the olfactory receptors in the nasal cavity leading to reduced enjoyment of
meal times and social interaction
Partial or total inability to masticate due to loss of bony supporting structure (mandible), exacerbated
by dental extraction, misalignment of the jaw and trismus, leading to the requirement for texture
modification, increased effort and reduced enjoyment of food, and social isolation
Reduced pressure to move the bolus into the pharynx occurs due to surgery or nerve damage, and
can be embarrassing and isolating, causing anxiety and depression
Prolonged meal times with risk of avoiding food and fluid, leading to inadequate diet, dehydration,
constipation and weight loss
Due to reconstruction or gastric transposition (pharyngolaryngo-oesophagectomy) requiring small
frequent meals, remaining upright for 1 hour post meal, and lying down with the head elevated
Functional impairment of the soft palate or motor activity of the graft can be embarrassing and
distressing, and require to be maintained whilst eating and drinking
Causes nausea, bloating, abdominal cramps and explosive diarrhoea; fear of food and eating is
common and changes in eating habits are required due to prolonged meal times and early satiety
Loss of smell
Difficulty chewing
Drooling and pocketing of
food and fluid
Reduced peristalsis
Oral regurgitation
Nasal regurgitation
Dumping syndrome
Poor wound healing
Risk of wound infection
Nerve injury
Chylous fistulae
Strictures and stenosis
Patient comorbidity factors
Examples include flap failure, dehiscence at anastomosis, necrosis and infection. Contributing factors
include previous radiotherapy, malnutrition and increased nutritional requirements, necessitating
assessment for vitamin and mineral supplementation
Occur in the oral cavity, pharynx or larynx, caused by previous radiotherapy and affect tissue healing
and swallowing, requiring alternative feeding
At wound site or chest with extensive or revision surgery and lengthy operations when entering into
or resecting part of the upper aerodigestive tract, increasing nutritional requirements
Damage to the trigeminal, facial, glossopharyngeal, vagus, accessory, hyoglossal and recurrent
laryngeal nerves affect swallowing coordination, chewing and taste, increasing the risk of aspiration
and fatigue during meals, as well as facial disfigurement
Can be a silent or reactive cough with food or fluid entering the lungs, requiring the patient to be nil
by mouth and needing alternative feeding
Tumour invasion or surgical trauma of the thoracic duct with <500 mL/day lymphatic drainage,
requiring conservative management or >600 mL/day over a prolonged period and suggesting surgical
Complete or partial obstruction of the food bolus, requiring dilatation with texture modification, and
smaller size food bolus with plenty of fluid and multiple swallows
Diabetes, renal impairment, malnutrition, previous surgery or radiotherapy, anaesthetics for procedure
and duration of the surgery
Table 7.15.5 Side effects of radiotherapy and nutritional consequences (source: Talwar 2010. Reproduced with permission of WileyBlackwell Publishing)
Side effect
Nutritional consequences
Taste changes
Diminished, distorted, abnormal and/or loss of taste (described as cardboard, metallic or
sandpaper) leading to food aversion and reduced intake
Oral mucosal reaction that can result in pain, infection or retching
Requires good oral hygiene, artificial saliva and food texture modification
Pre-existing or post treatment with tissue damage impairing wound healing
Reduced range of lingual motion and strength, impaired bolus formation and transport through
the oral cavity, prolonged transit time and increased residue occur in floor of mouth resections,
causing difficulty with chewing, taste changes and fatigue during meals
Impaired tongue base movement, delayed trigger of the swallow, reduced pharyngeal contraction,
reduced laryngeal function, reduced opening of the oesophageal sphincter, resulting in impaired
bolus clearance and aspiration
Silent or reactive coughing on food and fluid associated with fear of eating; can be due to
lethargy, weakness and reduced alertness secondary to malnutrition
Restricted ability to open the mouth, which can be due to pre-existing tumour obstruction,
radiation induced or reduced mastication over a prolonged period
Mandible incapable of healing itself or fighting infection due to poor blood supply, resulting in
reduced ability to masticate and limited mouth opening
Permanent tissue damage increasing risk of poor wound healing
Apathy and severe tiredness limiting physical function, as well as motivation with swallowing
increasing time and effort at meals with an overall reduced nutrient intake
Due to poor oral hygiene or exacerbated in the presence of xerostomia as food and fluid stick to
the teeth, there is no flushing effect from saliva and the teeth rapidly decay
Decreased salivary flow resulting in altered colonisation of the oropharynx, impaired bolus
preparation due to lack of saliva and increased thickness of sputum
Swallowing impairment of
oral phase
Swallowing impairment of
pharyngeal phase
Impaired wound healing
Dental caries
Table 7.15.6 Side effects of chemotherapy and nutritional
consequences (source: Talwar 2010. Reproduced with permission of Wiley-Blackwell Publishing)
Side effect
Nutritional consequences
Severe mucositis
Although radiation induced, this can be
exacerbated by the systemic effects of
the drug and can impair wound healing
Systemic or anticipatory; triggered by
taste, smell and anxiety
Reduced appetite accompanied by
reduced intake
Diminished, distorted, abnormal and/or
loss of taste (described as cardboard,
metallic or sandpaper), leading to food
aversion and reduced intake
Risk of dehydration and distressing to
the patient
Sore mouth significantly affecting food
Renal impairment can lead to nausea
and loss of appetite
Can lead to increased energy
expenditure and micronutrient
Nausea and
Taste and smell
Table 7.15.7 Consequences of malnutrition and dehydration
in head and neck cancer patients
Consequences of
Consequences of
Swallowing impairment and increased
risk of aspiration due to lethargy,
weakness and reduced alertness
Reduced strength of the cough and
mechanical clearance in the lungs
Impaired wound healing and increased
risk of infection due to decreased
muscle, respiratory, gut and immune
Higher risk of admission to hospital
and greater length and cost of hospital
Poor functional status and quality of
life due to lethargy and decreased
ability to mobilise, work and socialise
Increased morbidity and mortality
Decreased salivary flow resulting in
altered colonisation of the oropharynx
Impaired bolus preparation due to lack
of saliva and increased thickness of
Increased risk of aspiration due to
lethargy and mental confusion
Table 7.15.8 Professional consensus statement of dietetic
advice post oesophageal stent placement (British Dietetic Association’s Oncology Group, 2008)
Caution with
certain foods
Fluids only for 24 hours post insertion of
stent. Local policy needs to be agreed, as
many areas extend this to 48 hours
Role of fluid thereafter is to wash away
debris. There is no evidence base to
support the advice to use fizzy fluids. Fizzy
fluids may cause problems if acid reflux is
experienced. A stent positioned at the
distal end of the oesophagus may result in
Advise frequent consumption of any type
of fluid after consuming food
Education will depend on extent of
tumour, ability to chew, continuing
dysphagia and position/posture of patient
Gradual introduction of small amounts of
liquid/soft foods may be required
Importance of chewing well needs to be
Dietitians should be aware of any
limitations on food intake. Literature
provided should reflect individual need for
texture modification. Patients should be
advised to chew all food well, to sit
upright, not to rush eating and to drink
plenty of fluids. They should also be aware
of foods that are most likely to cause a
problem. Controversy remains about the
use of a standard list of foods to avoid,
but observational reports point to risk
• Bread and toast
• Egg
• Fish with bones
• Stringy, pithy fruit
• Stringy/hard raw vegetables
• Chips
Required by the majority of patients to
some extent
Table 7.15.9 Influence of dietary components on prostate
cancer risk [source: WCRF/AICR Report 2007. Reproduced with
permission of the World Cancer Research Fund International
Strength of evidence
Decreases risk
Increases risk
Foods containing
Foods containing
Selenium supplements
Pulses (legumes)
Foods containing
vitamin E
Limited (suggestive)
Milk and
Limited – no conclusion
Alpha-tocopherol, cereals (grains) and their products; dietary
fibre; potatoes; non-starchy vegetables; fruit; meats; poultry;
eggs; total fat; plant oils; sugar (sucrose); sugary foods and
drinks; coffee; tea; alcohol; carbohydrate; protein; vitamin A;
retinol; thiamine; riboflavin; niacin; vitamin C; vitamin D;
delta-tocopherol; vitamin supplements; multivitamins; iron;
phosphorus; zinc; other carotenoids; physical activity; energy
expenditure; vegetarian diets; Seventh Day Adventist diets;
body fatness; abdominal fatness; birth weight; energy intake
Table 7.15.10 Effect of hormone therapy on lipid profile (Fillippatos et al., 2008)
Hormone therapy
Low density
High density
Lutein hormone releasing hormone analogues
Not available
Table 7.15.11 Mineral and electrolyte changes with drugs
commonly used in stem cell transplantation
Therapeutic use
Biochemical side effect
Hypocalcaemia, other
electrolyte disturbances
Table 7.15.12 Dietary restrictions according to neutrophil
count (Leukaemia and Lymphoma Research, 2012)
Neutrophil count
Foods to restrict
<2.0 × 109
Mould ripened or blue veined cheeses
Unpasteurised dairy products
Raw or lightly cooked shellfish
Raw or undercooked meat, poultry or fish
Raw or undercooked eggs
Probiotic products
Fresh pâté
Raw or unpeeled fruit, dried fruit,
vegetables and salad
Unpasteurised fruit or vegetable juices or
Water or ice from wells, coolers or
bottled water
Ice cream from ice cream vans
Fresh nuts
Uncooked herbs, spices and pepper
Unpasteurised honey
Unnecessarily large packets of food items
< 0.5 × 109
Table 7.15.13 Examples of drugs used in the management of cancer cachexia
Further reading
Megestrol acetate
A synthetic progestogen, which
stimulates appetite;
mechanisms not fully known
but may induce
neuropeptide Y and suppress
proinflammatory cytokines
Improve appetite/ oral intake
Increases resting energy expenditure
Increases risk of thromboembolic events
Suppresses testosterone production in men
No improvements have been shown in
physical function, fatigue or lean body mass
Berenstein & Ortiz (2005)
Loprinzi et al. (1999)
Mantovanu et al. (2009)
Stimulate appetite
Maintains lean body mass
through affecting
proinflammatory cytokines
Can exacerbate cachexia due to myopathy,
insulin resistance and infections
Lower gastrointestinal motility, which
undermines the effect on appetite
No quality of life improvement
No quality of life or survival benefit
Jatoi et al. (2002)
Sarhill et al. (2003)
Strasser et al. (2006)
Khan et al. (2003)
Gordon et al. (2005)